A list of the most recent deficiencies for The Villas at New Brighton. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-11 | 2024-02-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-11 | 2024-02-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-11 | 2024-02-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-11 | 2024-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-09 | 2024-02-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-09 | 2024-01-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-11-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-17 | 2023-07-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-17 | 2023-07-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-17 | 2023-07-27 | Y |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-07-17 | 2023-07-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-07 | 2023-07-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-07 | 2023-07-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-07 | 2023-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-07 | 2023-07-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-28 | 2023-07-27 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-06-28 | 2023-07-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-03 | 2023-02-16 | Y |
| Keep all essential equipment working safely. | Health | 2022-11-09 | 2022-12-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-01 | 2022-10-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-01 | 2022-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-01 | 2022-10-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-01 | 2022-10-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-01 | 2022-10-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-01 | 2022-10-12 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-31 | 2022-10-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-31 | 2022-10-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-31 | 2022-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-31 | 2022-10-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-31 | 2022-10-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-31 | 2022-10-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-24 | 2022-06-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-24 | 2022-05-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-19 | 2022-05-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-19 | 2022-05-11 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-08 | 2022-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-13 | 2022-02-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-25 | 2021-09-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-25 | 2021-09-27 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-22 | 2021-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-08-20 | 2020-09-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-08-20 | 2020-09-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-08-20 | 2020-09-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-20 | 2020-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-20 | 2020-09-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-08-20 | 2020-09-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-08-20 | 2020-09-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-08-20 | 2020-09-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-08-20 | 2020-09-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-08-20 | 2020-09-29 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-08-20 | 2020-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-20 | 2020-09-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-08-20 | 2020-09-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-08-18 | 2020-09-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-08-18 | 2020-09-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-08-18 | 2020-09-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-08-18 | 2020-08-31 | N |
